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MSW Practicum

Students - Placement Ranking Form

Students who have completed their Profile on the portal and showed interest in 10 agencies can now rank the agencies they are interested
in order. Rank in order of interest (1 = most interested). In order to be considered for these placements, it is critical that students first show interest in 10 agencies on the portal prior to completing this form.

Students must be prepared to be matched with any of the top 10 agencies list and/or the 3 geographical areas listed on the portal. Please make your selections thoughtfully and ensure that you are able to meet the requirements of the placements you select (e.g. access to car, immunizations, police check, etc.)

**Placements are competitive, it is essential that students indicate interest in 10 agencies**

Full Name*:

Student ID*:

Laurier Email*:

(must be a valid WLU email address)Check here to send a copy of the completed form to this address.

Rank the placements you showed interest in on the portal. Rank in order of preference as follows: ID of placement, name of agency. For example -- Placement 1 - ID, agency name: 579, Joseph Brant Memorial Hospital

Placement 1 - ID, agency name:*:

Placement 2 - ID, agency name:*:

Placement 3 - ID, agency name:*:

Placement 4 - ID, agency name:*:

Placement 5 - ID, agency name:*:

Placement 6 - ID, agency name:*:

Placement 7 - ID, agency name:*:

Placement 8 - ID, agency name:*:

Placement 9 - ID, agency name:*:

Placement 10 - ID, agency name:*:

If you have listed any hospital placements in your top 10 placements, identify the areas (e.g. oncology, mental health, etc.) that you are interested in. Identify all areas of interest.*:

If you have listed any hospital placements in your top 10 placements, identify the areas (e.g. oncology, mental health, etc.) that you are NOT interested in. Identify all areas that you are NOT interested in*:

updated June 15/15

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